UCHealth Clinical Documentation Specialist RN in Aurora, Colorado
Clinical Documentation Specialist RN
This is a full-time, hourly position on UCHealth's CDI team. You may be based in Metro Denver, Colorado Springs or Fort Collins. You must be able/willing to travel to Aurora for staff meetings 2-3 times/year.
The Clinical Documentation Specialist RN is responsible for performing concurrent review of the clinical documentation in the written and electronic medical records in order to ensure compliant, appropriate and accurate reimbursement based on severity of patient illness, risk of mortality and level of services provided to patients.
Utilizing a collaborative approach with physicians, nursing staff, ancillary departments, and coding staff, ensures that clinical documentation is compliant, complete and accurate. The Clinical Documentation Specialist RN provides ongoing education and support to all members of the healthcare team in regard to clinical documentation in the medical record.
• Analyzes documentation of the clinical status of patients, current treatment plan, and past medical history; identifies potential gaps in provider documentation.
• Collaborates with physicians, case management, nursing, other patient care givers and coding staff to ensure medical record accurately reflects the clinical condition of patient.
• Collaborates with coding staff to ensure documentation of diagnoses and pre-existing co-morbidities are a complete and accurately reflect the care received, as well as patient's clinical status, acuity, severity of illness, and risk of mortality.
• Serves as a resource to providers to help link coding guidelines and medical terminology, to improve accuracy of the patient's severity of illness, risk of mortality, final code assignment and case mix index.
• Associates Degree from an NLN or CCNE accredited nursing program with a minimum of 1 year of related clinical experience or Baccalaureate Degree in Nursing from an NLN or CCNE accredited baccalaureate nursing program with a minimum of 1 year of related clinical experience. BSN is highly desired.
• 2 years of recent clinical experience in an acute inpatient nursing unit OR current work experience which requires frequent, appropriately assertive communication with physicians and other Licensed Independent Practitioners to clarify/discuss/recommend significant changes in patient's treatment/plan of care, and acute changes in patient condition, combined with at least 2 years of prior experience on a nursing care unit in an acute care facility.
• Current Colorado RN license.
• Current AHA certification in Basic Life Support (BLS). BLS through the American Heart Association or the American Red Cross CPR for the Professional Rescuer with card in-hand before start date. BLS or CPR card must be good through sixty days of hire. All life support certification cards must be issued by either the American Heart Association or the American Red Cross CPR for the Professional Rescuer. (American Red Cross for the Professional Rescuer is only good upon hire and all renewals will need to be through an American Heart Association sanctioned course.)
• Bachelor’s Degree in Nursing is highly preferred.
• ICU and/or strong MED/SURG background with the ability to assess and identify acute and chronic relevant clinical conditions.
• Certification in Specialty area.
• CCDS or CDIP certification.
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